HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (Pt.#1) clinical records reviewed for monitoring, the hospital failed to ensure that the level of observation was increased after a report of change in patient behavior to ensure patient is free from abuse.

Findings include:

1. On 6/06/2025, the hospital's policy titled, "Precautions, Sexual Acting Out" (revised 03/2025), was reviewed and required, "Patients are assessed for risk of sexual acting out behavior ... 1. Upon admission, patients will be assessed for any history of sexual acting out behavior including ... psychosis with sexual preoccupation or promiscuity ... 2. During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual act out behavior (i.e., inappropriate touching or sexual comments, etc.). 3. Any changes in behavior ... potential for sexual acting out behavior are to be reported. 4. The Charge Nurse will assess the patient and contact the attending physician/covering practitioner to communicate the change in behavior. 5. The practitioner shall order level of observation and precautions consistent with the assessed level of risk ..."

2. On 6/06/2025, the hospital's policy titled, "Observations-Patient" (revised 03/2025) was reviewed and required, "In order to maintain patient safety ... staff makes and documents routine safety rounds ... Levels of observations can be increased by the RN any time there is a concern ... if the patient's condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and an order for the observation level."

3. On 6/06/2025, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the Adult Behavioral Health Unit (3-East) on 05/27/25 through 06/02/25. The clinical record included the following:

-Psychosocial Assessment dated 05/27/25, "Trauma Assessment: (Pt.#1) was sexually abused by mother ... would make (Pt.#1) perform oral sex in front of others ... Reports a hx (history) of sexual abuse by biological father ... "

-Physician Orders dated 05/27/25, "Suicide Precautions, Assault Precautions, Q (every) 5 Minutes Monitoring."

-Psychiatric Evaluation (MD#1) dated 05/28/25 at 11:13 AM, "(Pt.#1) with a past medical history of bipolar disorder presenting with decompensated mania and psychosis including paranoid and persecutory delusions ... seen pacing in room ... observed talking to self and appeared to be responding to internal stimuli ... (Pt.#1) immediately went on a very long tangent about human trafficking and stated feels they have been human trafficked since the age of 3 ... states that boyfriend and parents are currently involved in trafficking (Pt.#1) ... Plan: Start Seroquel for mood stabilization ... Monitor for self-injury and safety; Psychotherapy, Milieu and Group therapy."

-Psychiatric Progress Note dated 05/29/25 at 10:20 AM, "(Pt.#1) pacing in the hallways ... continued to be disorganized with flight of ideas with various topics including ... leaving the hospital, concerns about human trafficking ... denies having any psychiatric illness ..."

-Nursing Progress Note (E#9) dated 05/30/25 at 5:29 AM, "Current Shift Assignment for 7PM-7AM; Appearance: Neat, well-groomed; Behavior: Attention Seeking/Hyperactive; Active Medical Problems: No active medical Problems ... Skin: Normal ... Pain: No; Narrative Note: (Pt.#1) alert and oriented ... No complaints of pain or distress. Pt denies SI (suicidal ideation)/HI (homicidal ideation) and free of harm to self and others." The nursing progress note did not include documentation indicating the staff (E#2) reported to the nurse that (Pt.#1) was making inappropriate sexual comments and fixated on staff (E#2) during shift, or to notify the Attending Psychiatrist of the change in behavior and an order to increase level of observation.

4. On 6/06/2025 at 10:45 AM, an interview was conducted with a BHA (E#2). E#2 stated that during their shift (05/29/25) throughout the night it was calm, there was another BHA (E#6) and a Nurse (E#9) working that night. E#2 reported that during rounding (Pt.#1) was pacing hallways and approached (E#2) several times and was being inappropriate towards E#2 by asking personal questions such does (E#2) having a girlfriend, (Pt.#1) at one point was handed a snack and a drink and (Pt.#1) rubbed (E#2's) hand inappropriately and asked (E#2) to sit on (Pt.#1's) lap. E#2 redirected (Pt.#1) and set boundaries several times and explained that this was inappropriate behavior. E#2 reported (Pt.#1's) behavior to the Nurse (E#9) and the other BHA (E#6). E#2 was told by the Nurse that they would keep an eye on (Pt.#1), and E#6 stood near (E#2) throughout the shift. E#2 stated that during rounding when necessary to observe (Pt.#1) while in their room E#2 was not in the room longer than a couple of seconds, rounding was alternated between E#2 and E#6.

5. On 6/06/2025 at 12:55 PM, an interview was conducted with a BHA (E#6). E#6 stated that E#6 worked on 05/29/25 with (E#2). E#6 stated that (E#2) informed E#6 and the Nurse (E#9) that (Pt.#1) was constantly being inappropriate with (E#2). E#6 stated they observed (Pt.#1) approach (E#2) approximately 6 times asking for water, asking inappropriate questions and making inappropriate remarks to (E#2). E#6 stated that the patient was not on SAO precautions, including after the nurse (E#9) was notified of the patient's behavior.

6. On 6/07/2025 at 11:22 AM, an interview was conducted with the Attending Psychiatrist (MD#1). MD#1 stated that on admission the patients are assessed for history of SAO behavior and/or sexual preoccupation. MD#1 stated that initially MD#1 did not feel that (Pt.#1) required to be on SAO precautions, (Pt.#1) was not making any active allegations or acting inappropriately. (Pt.#1) was fixated on having been trafficked their whole life. Precautions for SAO can be initiated by the nurse.